The Palatal Injection: Dentistry’s Most Painful Shot

Probably the most frequently commented upon topic on this blog involves what the majority of patients dread the most: the shot. As a result, I’ve posted many articles related to dental injections, including articles on novocaine (no, we don’t use it anymore), epinephrine (the racing heart does not mean you are allergic to it), why some people/teeth are hard to get numb (over ten different reasons), etc.

I’ve also done a two part series on what factors cause some dental injections to hurt more than others (located here and here). However, given the number of comments and questions about palatal injections, it was warranted to create an individual post on what can be considered dentistry’s most painful injection.

What is a Palatal Injection?

This may seem somewhat obvious but it is worth explaining. We’ll start with a photo.

Injection into the palate on the right side. If it looks painful, it’s because it is painful.

In a palatal injection, local anesthetic is injected into the soft tissue covering the hard palate, just adjacent to the tooth/teeth to be worked upon. It is not an injection into the soft palate nor the uvula. And it is only done for top teeth.

These types of injections are performed when you need the gum tissue on the roof of the mouth to be numb and/or when the procedure requires the tooth to be super numb (like an extraction or root canal). In my experience, for most fillings of upper teeth, palatal injections are NOT needed.

Why Palatal Injections Hurt so Darn Much!

There are two major reasons to explain why these hurt so much:

Tightness/Density – the tissue lining the hard palate is very dense and tight. There’s no “give” to it. The needle initially goes in and is accompanied by a pinch. That pinch is actually not the worst part. The worst part is when the local anesthetic fluid is forced in. There’s literally no room for it because the tissue is so dense. That forcible entry of fluid into this tissue is what causes the pain.

Traditional topical anesthetic does little to help with palatal injections.

Want an analogy? Imagine you have a turkey baster injector. Plunge the injector deep into the breast or thigh. Then try to inject. It will take GREAT force to get even a little fluid into this dense muscle. This is like a palatal injection. Next, move the tip of baster until it is just at the border of the thigh and skin. Then try to inject. There is little to no resistance. Fluid goes in with great ease, taking advantage of the looseness at the skin/muscle junction. This is like most other dental injections.

Traditional Topical Anesthetic Doesn’t Work Well – traditional topical anesthetic, a.k.a numbing jelly, doesn’t penetrate the tissue very easily, regardless of how long you wait. As a result, it exerts little to no effect, thus offering little to no pain relief.

How Palatal Injection Pain Can be Reduced

Fortunately, there are ways to reduce the pain associated with palatal injections. Note, however, that these are all done by the dentist himself/herself (except the last one which involves both dentist and patient).

Application of pressure can reduce the pain.

Waiting – in nearly all cases, if you are going to get an injection on the palate, you will also receive an injection on the cheek side. In many cases, if the dentist waits 10 minutes or so after the “cheek side” injection, some of that local anesthetic will work its way over and partially anesthetize the palate. This will make it so that the palatal injection is less painful.

Pressure – placing firm pressure with a cotton applicator for at 30 seconds can slightly numb or obtund the pain sensation. The pressure is applied on the roof of the mouth right where the injection is going to go.

Super Topical Anesthesia – some dentists will use a pharmacy compounded topical anesthetic that is several times more powerful than traditional topical. Using this correctly can also reduced the pain.

Cold – application of a cold cotton applicator with pressure right before the injection can also reduce the sensation.

Sedation – if you are sedated, you are unlikely to even feel the painful injection, let alone remember it. Sedation dentistry is very effective – I do it routinely in my office.

Not all dentists employ the above techniques. But all dentists are aware of the painful nature of this injection and do their best to only do it when necessary.

Comments

I had a shot at a dentist appointment recently – I’m not sure if it was palatal specifically or if it was another numbing agent, but it was a really weird experience. Reading through this, it makes a bit more sense. The sensation was less ‘prickly’ and much more ‘pressure’. It felt like something was trying to expand in my gum area with a slight burning sensation to it. I didn’t realize that dental tissue was so dense – I’m sure that’s the reason why it felt the way it did! Very cool to read about – thanks!

I got somewhere between 5 and 10 palatal injections in addition to the ones in the cheek area. When I got home the area was dark red and blue. A week later, I still can’t chew anything hard because of just how much the injection site hurts. When is it going to stop hurting? It really really hurts.

Lauren,
That is hard to tell without an exam and a clinical history and is dependent upon many factors. It’s very much dependent on the procedure performed. For example, for a root canal, the clamp that holds the rubber dam in place can pinch the gum tissue on the palate, leading to several days worth of soreness. But the best thing to do is to call your dentist and have him/her evaluate it.

hello, I am a senior citizen and I have dental work here locally at a dental clinic. I’ve had a lot of dental work done, and many shots in the gum, and although they are somewhat painful they are tolerable…. recently on the upper right-hand side of my mouth I had a cracked crown… the lady dentist was extremely negative and pessimistic, and with my Advanced age, I have been able to tell people what I think and I told her that she was being overly pessimistic and just do the work… she gave me a shot in my gum and then she gave me a shot on the roof of my mouth which was incredibly painful… she spent about 15 minutes preparing the tooth for the crown and told me that the next day she would take the impression.. I said okay, but I’m the next day she gave me another shot in my gum and a shot in the roof of my mouth and I cried out in pain. I asked her why she just couldn’t have finished up with the impression the previous day and found it necessary to give me another shot in the gum and another shot in the roof of my mouth only for about 10 more minutes of work. needless to say I was quite upset… the manager of the credit came in and told me that the government does not allow dentist to spend more than a certain amount of time with each patient which I certainly felt was a bunch of crock since the total work on my mouth took about 30 minutes on her part… I was hopping mad and I still am hopping mad… so I am going in next week for her to deliver the actual crown and she better not give me any more shots I think the reason why she did that was in her little way to get back at me… personally what she did I considered to be evil evil evil.

Every patient is unique so I really can’t know the specifics of your case. But two points:

1. Doing a crown on an upper tooth sometimes requires that the gums be numb there. The only way to numb them effectively is with an injection. The alternative is to feel pain.

2. In many “clinics” here in the U.S., especially those that participate in many government insurance programs, the reimbursement is such that there is an incentive to keep the time allotted for each visit down to a minimum. In most private practices, that is not the case. I know many good dentists who work in these “clinics” whose hands are tied – they are literally forced by the Clinic Director to separate things into separate appointments. So, instead of blaming the dentist, I suggest you direct your anger at the Director of the clinic as to why there are policies like this.

Oh my goodness, I have had palatal injections in the past. This time was different. I had a surgical procedure and there was no time to pamper. That injection was delivered with full force and it burned like hot searing and roaring pain. I thought my head was going to explode. All I could do was laugh because it was unexpected. I love the doctor and we are friends. I forgave him and appreciated the profound anesthesia since surgical pain was more uncomfortable than a few seconds of hell.

I had a wisdom tooth extracted about 5 months ago.. ever since, the roof of my mouth has been hurting… i now have a lump in my palate ? like its much thicker… I heard a crunching noise when the injection was given and was in so much pain… also it is hard for me to eat and raw vegetables or fresh fruits because it hurts to chew if it hits the roof of my mouth… whats wrong with this …
Thank you for any information. Diane Temchuk

I am not aware of any reason why there would be a crunching sound originating from within your mouth due to injection. It’s possible it originated from the mechanics of the actual syringe. Then dentist may need to exert considerable force to actually depress the plunger to get anesthetic to flow in. The noise could have come from there.

I actually just experienced the same thing and the crunching sound was not the force used on the plunger. I actually believe the crunching noise was the dentist hitting either my tooth or my bone, which created the very excruciating pain I experienced. I am actually a very petite person and I don’t think he dentist realized the force he used on me was excessive. I also cried for several hours it hurt so much.

My brother got an injection in his palate for an extraction. A high stress hospice situation at home plus the procedure created sores to appear behind his upper teeth on his gums. Very sore, couldn’t eat for weeks and lost a considerable amount of weight. The hospice situation has ended with the death of his wife. His mouth condition cleared but is now back. The oral surgeon said the injection triggered the sores along with the stress in the first bout of this misery. Now what. Why is this coming back and what is it??

If they are on opposite sides then yes, you will likely need two palatal injections.
There are techniques to make it less painful. I typically inject on the cheek side – which is virtually painless – and then wait 10 minutes. This allows for some of the anesthetic to migrate over. In doing this, the palatal injection can be less painful. There are other techniques – too lengthy to list here – that can be done as well.

I had a root canal on Wednesday morning, it’s now Saturday night and the roof of my mouth on the right hand side where I had a palatal infection is still really hurting and I also can’t stand any pressure on the tooth with was treated. If I bite on it, even subverting really soft, it makes me jump it’s so painful. The roof of my mouth also has a throbbing and swollen sensation. Is this just from the injection or could it be something else? How long will it last for? It’s really getting me down.

Occasionally, the site of a palatal injection can be sore and painful for several days after. And in addition, it can sometimes ulcerate a bit. It is uncomfortable, but typically resolves. Pain from biting on a tooth that has had a root canal can also occur, for several days and sometimes even a week or so.

This said that dentists only give the shot when needed and I’ve heard people say they’ve gotten root canals and teeth pulled without this shot and said the samething. That, again, only when they absolutely need to. So what factors do they decide that they need to do this certain shot. Is it certain teeth? Your pain level that you go into the dentist’s office with? What exactly?

That is an excellent question. There are a lot of factors that go into whether the injection is needed. But, generally speaking, the more invasive the procedure, the more likely it is that the injection will be needed. Root canals and extractions – in nearly all cases, anesthesia of the palate is needed.

With some skill and patience, a palatal injection can be done with little to no pain to the patient. This could account for individuals who’ve stated that they’ve had extractions without that injection. They may have had one but just did not feel it.

For a patient with an active toothache, you almost always need to give a palatal injection.

I had some ruptured roots taken out after a broken crown came out. the injection into the roof of my mouth was very painful but I was warned by my dentist that this would be the case so I was prepared. However, the injection site swelled up into a semi hard grey lump. The dental nurse said not to worry as it will “disperse” but I’m worried. Anyone have any information as to what went wrong?

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